Professional Documents
Culture Documents
Defining Characteristics: Lack of motivation to initiate and/or follow through with goal-directed or
purposeful behavior; fluctuation in psychomotor activity; misperceptions; fluctuation in cognition;
increased agitation or restlessness; fluctuation in level of consciousness; fluctuation in sleep-wake
cycle; hallucinations
Related Factors: 60 years of age; dementia; alcohol abuse; abuse; delirium; uncontrolled pain;
multiple morbidities and medications
Information Processing
Memory
Sleep
Client Outcomes
Delusion Management
Assess clients behavior and cognition systematically and continually throughout the
day and night as appropriate. Rapid onset and fluctuating course are hallmarks of delirium
(Murphy, 2000). The Confusion Assessment Method is sensitive, specific, reliable, and easy
to use (Inouye et al, 1990). Nurses play a vital role in assessing acute confusion because
they provide 24- hours-a-day care and see the client in a variety of circumstances (Marr,
1992). Delirium always involves acute change in mental status; therefore knowledge of the
clients baseline mental status is key in assessing delirium (Flacker, Marcantonio, 1998).
o Attention
Treat underlying causes of delirium in collaboration with the health care team:
Establish/maintain normal fluid and electrolyte balance; establish/maintain normal
nutrition, body temperature, oxygenation (if patients experience low oxygen saturation
treat with supplemental oxygen), blood glucose levels, blood pressure.
Review medication. Medication is one of the most important modifiable factors that
can cause delirium, especially use of anticholinergics, antipsychotics, and hypnosedatives
(Flacker, Marcantonio, 1998).
Decrease caffeine intake. Decreasing caffeine intake helps to reduce agitation and
restlessness (Rapp, Iowa Veterans Affairs Nursing Research Consortium, 1997).
Modulate sensory exposure and establish a calm environment. Extraneous lights and
noise can give rise to agitation, especially if misperceived. Sensory overload or sensory
deprivation can result in increased confusion (Rosen, 1994). Clients with a hyperactive
form of delirium often have increased irritability and startle responses and may be acutely
sensitive to light and sound (Casey et al, 1996).
Identify self by name at each contact; call patient by his or her preferred name.
Appropriate communication techniques for clients at risk for confusion (Rapp, Iowa
Veterans Affairs Nursing Research Consortium, 1997).
Provide supportive nursing care. Delirious patients are unable to care for themselves
as a result of their confusion. Their care and safety needs must be anticipated by the nurse
(Foreman, 1999).
Identify, evaluate, and treat pain quickly (see care plan for Acute Pain). Untreated
pain is a potential cause for delirium.
Geriatric
Mobilize client as soon as possible; provide active and passive range of motion. Older
clients who had a low level of physical activity before injury are at a particular risk for
acute confusion (Matthiesen et al, 1994).
Provide sufficient medication to relieve pain. Older clients may give inaccurate pain
histories; underreport symptoms; not want to bother the nurse; and exhibit restlessness,
agitation, or increased confusion (Matthiesen et al, 1994).
Because anxiety and sensory impairment decrease the older client's ability to integrate
new information, explain hospital routines and procedures slowly and in simple terms,
repeating information as necessary (Matthiesen et al, 1994).
Provide continuity of care when possible (e.g., provide the same caregivers, avoid
room changes). Continuity of care helps decrease the disorienting effects of hospitalization
(Matthiesen et al, 1994).
If clients know that they are not thinking clearly, acknowledge the concern. Confusion
is very frightening (Matthiesen et al, 1994).
Do not use the intercom to answer a call light. The intercom may be frightening to an
older confused client (Matthiesen et al, 1994).
Keep client's sleep-wake cycle as normal as possible (e.g., avoid letting client take
daytime naps, avoid waking clients at night, give sedatives but not diuretics at bedtime,
provide pain relief and backrubs). Acute confusion is accompanied by disruption of the
sleep-wake cycle (Matthiesen et al, 1994).
Maintain normal sleep/wake patterns (treat with bright light for 2 hours in the early
evening). This facilitates normal sleep/wake patterns (Rapp, Iowa Veterans Affairs Nursing
Research Consortium, 1997).
Monitor for acute changes in cognition and behavior. An acute change in cognition and
behavior is the classic presentation of delirium. It should be considered a medical
emergency.
Client/Family Teaching
Teach family to recognize signs of early confusion and seek medical help. Early
intervention prevents long-term complications (Rapp, Iowa Veterans Affairs Nursing
Research Consortium, 1997).